Case Report Misdiagnosis of Extensive Maxillofacial...

Case ReportMisdiagnosis of Extensive MaxillofacialInfection and Its Relationship with PeriodontalProblems and Hyperglycemia

Cristian Statkievicz, Leonardo P. Faverani, Pedro Henrique Silva Gomes-Ferreira,Gabriel Ramalho-Ferreira, and Idelmo Rangel Garcia-Junior

Department of Surgery and Integrated Clinic, Aracatuba Dental School, Universidade Estadual Paulista (UNESP),16015-050 Aracatuba, SP, Brazil

Correspondence should be addressed to Cristian Statkievicz; [email protected]

Received 12 October 2015; Accepted 14 December 2015

Academic Editor: Giuseppe Colella

Copyright © 2016 Cristian Statkievicz et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Background. Complex dental infections can reach distant areas of the alveolar process, invading the secondary fascial spaces.Objectives. This case report aims to show a misdiagnosis of odontogenic infection and a great need for dentist in the hospitalenvironment. Case Report. A male patient presented facial asymmetry and trismus, while the facial CT examination showeda hyperdense mass involving the left masseteric, pterygomandibular, and superficial temporal regions. The patient was thenreferred to oral oncology center by emergency physician with cancer suspicion. After 15 days, the patient returned to the sameemergency room and was attended by the surgical and maxillofacial trauma team, presenting tachycardia, tachypnea, dysphagia,and trismus. During anamnesis, the patient reported being an uncontrolled diabetic. In intraoral exam, a poor oral condition andgeneralized periodontitis were observed.Results. Correct diagnosis of odontogenic infectionwas established and adequately treated.Conclusions. Symptomatology bland may mask the severity of an infection; every increase in volume associated with trismus, poororal hygiene with or without hyperglycemia should be heavily investigated for the presence of an infectious process. It emphasizesthe importance of a dentist working with the physician in emergency room.

1. Introduction

Maxillofacial infections are usual in patients of all ages,representing a substantial risk to life when reaching deepfacial spaces [1]. The signs and symptoms are evident dueto proximity between nerves, muscles, and ligaments, whichquickly impairs the function of affected region, leading topain and trismus [2]. Although well-defined, facial anatomypresents peculiar ways for infection spreading, which, wheninvaded, communicate with each other being able to storelarge amounts of pus, what may cause upper airways com-pression and/or face asymmetry, requiring a fast and accuratetreatment [3].

In general, the computed tomography (CT) assists inthe identification of infection limits, which is vital for aprecise diagnosis [1] and provides the surgeon conditionsfor appropriate surgical drainage, along with cause removal.

These two steps are the basis for therapy, supported by theadministration of specific antibiotics [4, 5].

Infectious processes within the oral cavity are gener-ally associated with an inadequate oral hygiene, periodon-tal disease, and caries [6], being exponentially aggravatedin immunosuppressed and especially diabetic patients [7].Therefore, the dentist or doctor must keep odontogenicinfection under suspicion when a painful edema is observedin face or neck [2]. Thus, a specialized consultation with adentist or an oral andmaxillofacial surgeon can avoid seriouscomplications and save lives [2].

Although it is hard to determine whether an infectionwill get worse at the moment the patient is admitted fortreatment [6], the triad anamnesis, physical examination, andimage tests should be performed thoroughly.Thus, this studyaims to highlight, through a case report, the importance of

Hindawi Publishing CorporationCase Reports in DentistryVolume 2016, Article ID 5960546, 4 pageshttp://dx.doi.org/10.1155/2016/5960546

2 Case Reports in Dentistry

Figure 1

Figure 2

dentists or oral and maxillofacial surgeons in the diagnosisand treatment of maxillofacial infections.

2. Case History

A 46-year-old male patient attended the emergency room ofthe Santa Casa de Misericordia de Aracatuba Hospital, SP,complaining about facial pain and swelling (Figure 1). Onphysical examination, left hemiface asymmetry and trismuswere observed, while the facial CT examination showeda hyperdense mass involving the left masseteric, pterygo-mandibular, and superficial temporal regions (Figures 2 and3). The patient was then referred to oral oncology centerwith cancer suspicion. However, he did not attend the oraloncology center.

After 15 days, the patient returned to the same emergencyroom and was attended by the surgical and maxillofacialtrauma team, presenting tachycardia, tachypnea, dysphagia,sore throat and breathing difficulty, trismus, and edema withfloatation point in the temporal region. During anamnesis,the patient reported being uncontrolled diabetic, so a quick

Figure 3

Figure 4

glucose test was performed noting a 600mg/dL glucose level.In intraoral exam, a poor oral condition and generalizedperiodontitis were observed (Figure 4). The diagnosis wasa complex odontogenic infection involving the masseteric,pterygomandibular, and superficial temporal spaces, con-firmed by computed tomography.

The treatment started immediately with intravenousantibiotic prophylaxis with 2 g sodium cephalothin (Keflin,Uniao Quımica, Brasilia, DF, Brazil) and 500mg metron-idazole (Sanofi-Aventis Pharmaceuticals Ltd., Sao Paul, SP,Brazil) and administration of 10 IU insulin. The surgicalprocedure was conducted under general anesthesia andinitiated by the location of floatation point in temporal region(Figure 5), where an aspiration punction for antibiogramculture and surgical drainage of superficial temporal spaceby Gillies technique with installation of a Penrose drain wereperformed (Figure 6). Two oral incisions were performed toaccess the masseteric and pterygomandibular spaces. Then,because of periodontal conditions and social-cultural aspectof the patient, a serial extraction was indicated (Figures 7 and8). On the second day after surgery, the patient presenteda good general condition and good mouth opening. Theantibiotic therapy was 1 g ceftriaxone and was continued for48 hours after symptom remission. The patient was referredto a dentist for rehabilitation with total prosthesis (Figure 9).

3. Discussion

Dental infection starts with pulp necrosis, which is dis-seminated to tissues through the apical foramen, reaching

Case Reports in Dentistry 3

Figure 5

Figure 6

Figure 7

areas distant from the infection focus [8]. In a study with185 patients suffering from deep neck infection, 50% of thecases were odontogenic [9], such as the case reported inour study. The current aspect of diagnosis and treatment ofhead and neck infections has improved due to technologicaladvances in imaging and different types of antibiotics [10].However, there is a low incidence of complications in patientswith predisposing diseases for the development of infectiousprocesses [5].

Uncontrolled diabetesmellitus can lead to high blood glu-cose levels, which contribute to a more aggressive infectioncourse, owing to a deficiency in chemotaxis, phagocytosis,and bactericidal function. These factors predispose longperiods of hospitalization increasing the risk of complications

Figure 8

Figure 9

[7]. According to this report, a 600mg/dL glycemic rateexacerbates infectious process and reduces pharmacologicaleffect of antibiotics, making glycemic blood control a keyfactor in the cure of dental infection.

The clinical signs and symptoms of facial infection areremarkable, especially in superficial areas such as temporaland buccal space, clinically observed as a pronounced vol-umetric increase in the region [2]. However, some patientswho exhibitmilder signsmay underestimate the case severity.Among the facial areas, when pterygomandibular space isaffected, it should be treated aggressively, due to the possi-bility of contamination passing the edge of medial pterygoidmuscle reaching the pharyngeal space [2].

Although not necessary in superficial infections, the CTscan is extremely valuable when the infection reaches deepspaces and when associated with an experienced clinicalexamination it is possible to identify clinically importantpus cavities [1]. However, an evaluation performed by anonspecialized professional can lead to misdiagnosis.

The cure of dental infections is usually achieved withoutmajor complications. Nevertheless, it is recommended thatthe dentist/doctor includes oral cavity as one of the mainareas to be evaluated on physical examination in patientswith painful edema in the head and neck region, investigatingpossible associated diseases that may be supporting theinfection.

4 Case Reports in Dentistry

A problem in emergency attendance is the lack of knowl-edge from the side of the physician about dentistry comor-bidities. Most misdiagnoses of head and neck infectionshappened due to first clinical examination failure; sometimes,it can be confused with tumor lesion. In this case, the firstattendance led to wrong diagnosis and it could promoteseveral complications, including death.Therefore, an oral andmaxillofacial surgeon is essential to emergency room.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

References

[1] A. Gonzalez-Beicos and D. Nunez, “Imaging of acute head andneck infections,”Radiologic Clinics of NorthAmerica, vol. 50, no.1, pp. 73–83, 2012.

[2] T. R. Flynn, “The swollen face: severe odontogenic infections,”Emergency Medicine Clinics of North America, vol. 18, no. 3, pp.481–519, 2000.

[3] A.Wabik, B. K. Hendrich, J. Nienartowicz, M. Guzinski, andM.J. Sąsiadek, “Odontogenic inflammatory processes of head andneck in computed tomography examinations,” Polish Journal ofRadiology, vol. 79, no. 1, pp. 431–438, 2014.

[4] J. S. Jundt and R. Gutta, “Characteristics and cost impact ofsevere odontogenic infections,” Oral Surgery, Oral Medicine,Oral Pathology and Oral Radiology, vol. 114, no. 5, pp. 558–566,2012.

[5] D. Opitz, C. Camerer, D.-M. Camerer et al., “Incidence andmanagement of severe odontogenic infections—a retrospectiveanalysis from 2004 to 2011,” Journal of Cranio-MaxillofacialSurgery, vol. 43, no. 2, pp. 285–289, 2015.

[6] S. Ylijoki, R. Suuronen, H. Jousimies-Somer, J. H. Meurman,and C. Lindqvis, “Differences between patients with or withoutthe need for intensive care due to severe odontogenic infec-tions,” Journal of Oral and Maxillofacial Surgery, vol. 59, no. 8,pp. 867–872, 2001.

[7] J. S. Chang, K. H. Yoo, S. H. Yoon et al., “Odontogenic infectioninvolving the secondary fascial space in diabetic and non-diabetic patients: a clinical comparative study,” Journal of theKorean Association of Oral and Maxillofacial Surgeons, vol. 39,no. 4, pp. 175–181, 2013.

[8] C. T. M. H. Saito, J. L. Gulinelli, H. F. Marao et al., “Occurrenceof odontogenic infections in patients treated in a postgradua-tion program on maxillofacial surgery and traumatology,” TheJournal of Craniofacial Surgery, vol. 22, no. 5, pp. 1689–1694,2011.

[9] T.-T. Huang, T.-C. Liu, P.-R. Chen, F.-Y. Tseng, T.-H. Yeh, andY.-S. Chen, “Deep neck infection: analysis of 185 cases,”Head &Neck, vol. 26, no. 10, pp. 854–860, 2004.

[10] I. C. Uluibau, T. Jaunay, and A. N. Goss, “Severe odontogenicinfections,” Australian Dental Journal, vol. 50, supplement, no.4, pp. S74–S81, 2005.

Submit your manuscripts athttp://www.hindawi.com

Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

Oral OncologyJournal of

DentistryInternational Journal of



International Journal of

Biomaterials


BioMed Research International


Case Reports in Dentistry


Oral ImplantsJournal of


Anesthesiology Research and Practice


Radiology Research and Practice

Environmental and Public Health

Journal of


The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014


Dental SurgeryJournal of

Drug DeliveryJournal of



Oral DiseasesJournal of


Computational and Mathematical Methods in Medicine

ScientificaHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

PainResearch and TreatmentHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

Preventive MedicineAdvances in


EndocrinologyInternational Journal of



OrthopedicsAdvances in

Case Report Misdiagnosis of Extensive Maxillofacial...

Documents

Transcript of Case Report Misdiagnosis of Extensive Maxillofacial...